There is no evidence that the increase in ER use is driven by pent-up demand that dissipates over time; instead, the effect of Medicaid on ER use persists over at least the first 2 years of coverage.

There is no evidence that Medicaid coverage makes use of the physician’s office and use of ERs substitutes for one another.

Increased ER Visits Has Adverse Health Outcomes

When a person uses the ER for non-emergency care, at least two problems result. First, the person doing this is receiving care in an extremely inefficient setting—the costs are much higher and the providers have not specialized in treatment of non-emergency health care services. Second, the person is contributing to crowding in the ER, which can affect the access to care of other people, including those experiencing genuine health emergencies.

A 2014 study that reviewed 11 previous studies concluded that ER crowding “is a major patient safety concern associated with poor patient outcomes.” Of the 11 studies reviewed, three found a significant positive relationship between ER crowding and mortality either among patients admitted to the hospital or discharged home, and five found that crowding was associated with higher rates of patients leaving the ER without being seen.

These conclusions were consistent with a 2009 study on the same topic. The authors reviewed 41 previous studies, concluding that ER crowding “is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ER against medical advice or without being seen.”

ACA Medicaid Expansion Much More Expensive Than Projected

The government’s most recent Medicaid Actuarial Report contained the striking finding that government spending on Medicaid expansion enrollees was roughly $6,366 per enrollee in fiscal year 2015, 49% higher than the predicted amount of $4,281. In July, I wrote that the much higher-than-expected spending was largely the result of the federal government’s 100% reimbursement of state spending on expansion enrollees.

While the government forecasters failed to anticipate how states would respond to the 100% federal reimbursement, states had an incentive to pay insurance companies very high payment rates for the expansion population. High payment rates make insurers and hospitals happy, and the cost is dispersed to federal taxpayers. Based on the new Oregon study, Medicaid expansion enrollees’ high use of ERs—potentially because of an inability to find physicians accepting new Medicaid enrollees—is likely a contributing factor to the large Medicaid expansion cost overrun.

Another Reason Against Medicaid Expansion

The Oregon Medicaid experiment continues to produce substantial evidence that Medicaid expansion is a poor use of taxpayer dollars. From the Oregon Medicaid experiment, we know that Medicaid expansion does not seem to produce better physical health outcomes, that expansion enrollees receive low benefit relative to the cost, and that ER use surges. Since a spike in ER use likely produces adverse outcomes for other people with emergency health needs, this secondary effect also needs to be part of state lawmakers’ decisions as they weigh the wisdom of either adopting or reversing Medicaid expansion.